C-reactive protein clustering to clarify persistent inflammation, immunosuppression and catabolism syndrome

Simultaneous detection of C-reactive protein and lipopolysaccharide based on a dual-channel electrochemical biosensor for rapid Gram-typing of bacterial sepsis

Sepsis is a life-threatening multi-organ failure syndrome, with bacterial infections being the most common cause. Rapid Gram-typing is imperative to assist in antibiotic intervention. C-reactive protein (CRP) and lipopolysaccharide (LPS) are effective biomarkers for discerning the Gram type of bacteria but differ by several orders of magnitude in clinical detection, thereby impeding their simultaneous detection. And two independent methods are time-consuming and laborious. In this study, a dual-channel electrochemical biosensor was developed for simultaneous detection of LPS and CRP. Under optimal conditions, linear ranges of LPS (0.5-1000 pg/mL) and CRP (0.1-20 μg/mL) were obtained in line with the clinical evaluation scopes. In simulated sample tests, Gram-positive, Gram-negative, and healthy plasma samples were clearly distinguished by the developed biosensors, and these results were consistent with that of enzyme-linked immunosorbent assay (ELISA). In addition, the results of the plasma samples tested by the electrochemical biosensor matched those derived from blood cultures in the laboratory. Collectively, the electrochemical biosensor was expected to provide the scientific basis for the rapid Gram-typing and point-of-care detection of bacterial sepsis.

Post-intensive care syndrome: Recent advances and future directions

Post-intensive care syndrome comprises physical, cognitive, and mental impairments in patients treated in an intensive care unit (ICU). It occurs either during the ICU stay or following ICU discharge and is related to the patients' long-term prognosis. The same concept also applies to pediatric patients, and it can greatly affect the mental status of family members. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. We highlight new topics, future directions, and strategies to overcome post-intensive care syndrome among people treated in an ICU. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.

Delayed-Onset Organ/Space Surgical Site Infection Worsens Prognosis in High-Risk Stage II and III Colorectal Cancer

BACKGROUND

It is unclear how early- and delayed-onset organ/space surgical site infections (SSIs) affect the long-term prognosis of patients with colorectal cancer, who are potential candidates for adjuvant chemotherapy. This study aimed to investigate the association between the timing of SSI onset and clinical outcome.

METHODS

This retrospective, multicenter cohort study evaluated patients who were diagnosed with high-risk stage II or III colorectal cancer and underwent elective surgery between 2010 and 2020. Five-year recurrence-free survival (RFS) was the primary endpoint and was compared between early SSI, delayed SSI (divided based on the median date of SSI onset), and non-SSI groups.

RESULTS

A total of 2,065 patients were included. Organ/space SSI was diagnosed in 91 patients (4.4%), with a median onset of 6 days after surgery. The early-onset SSI group had a higher proportion of patients with Clavien-Dindo grade ≥IIIb SSI than the delayed-onset SSI. Patients who received adjuvant chemotherapy (AC) had earlier organ/space SSI onset than those who did not. The adjusted hazard ratio of 5-year RFS in the delayed-onset SSI was 2.58 (95% confidence interval: 1.43-4.65; p = 0.002): higher than that in the early-onset SSI, with the non-SSI as the reference.

CONCLUSIONS

Delayed-onset organ/space SSI worsened long-term prognosis compared to early-onset, and this may be due to delayed initiation of AC. Patients who are clinically suspected of having lymph node metastasis might need additional intervention to prevent delays in commencing AC due to the delayed SSI.

Development and Validation of a Novel Method for Converting the Japan Coma Scale to Glasgow Coma Scale

BACKGROUND

The Japan Coma Scale (JCS) is the most frequently adopted method for evaluating level of consciousness in Japan. However, no validated method for converting the JCS to the Glasgow Coma Scale (GCS) exists. The aims of the present study were to develop and validate a method to convert the JCS to GCS.

METHODS

This is a multicenter retrospective analysis involving three emergency departments (EDs) in Japan. We included all adult patients who visited the ED between 2017 and 2020. The participating facilities were divided into two cohorts-one cohort to develop a table to convert the JCS to GCS (development cohort), and the other cohort to validate the conversion table (validation cohort). The conversion table of the JCS to GCS was developed based on the median values of the GCS. The outcome was the concordance rate between the JCS and GCS.

RESULTS

We identified 8,194 eligible patients. The development cohort included 7,373 patients and the validation cohort included 821 patients. In the validation cohort, the absolute and relative concordance rates were 80.3% (95% confidence interval, 77.4-82.9%) and 93.2% (95% confidence interval, 91.2-94.8%), respectively.

CONCLUSION

This study developed and validated a novel method for converting the JCS to GCS. Assuming the offset by a single category between the JCS and GCS is acceptable, the concordance rate was over 90% in the general adult patient population visiting the ED. The conversion method may assist researchers to convert JCS scores into GCS scores, which are more commonly recognized among global audiences.

Clinical treatment for persistent inflammation, immunosuppression and catabolism syndrome in patients with severe acute pancreatitis (Review)

Severe acute pancreatitis (SAP) is a severe disease with a high prevalence and a 3-15% mortality worldwide, and premature activation of zymogen for any reason is the initial factor for the onset of SAP. Gallstone disease and heavy alcohol consumption are the two most common etiologies of SAP. Persistent inflammation, immunosuppression and catabolism syndrome (PICS) is a life-threatening illness, and there are no effective treatments. The relapse state of PICS mainly leads to high mortality due to septic shock or severe trauma, both of which are dangerous and challenging conditions for clinicians. Thus, it is important for medical staff to identify patients at high risk of PICS and to master the prevention and treatment of PICS in patients with SAP. The present review aims to increase the understanding of the pathogenesis of PICS, produce evidence for PICS diagnosis and highlight clinical treatment for PICS in patients with SAP. With this information, clinical workers could implement standardized and integrated measures at an early stage of SAP to stop its progression to PICS.

Patterns of inflammatory immune responses in patients with septic shock receiving vitamin C, hydrocortisone, and thiamine: clustering analysis in Korea

BACKGROUND

Sepsis is characterized by heterogeneous immune responses that may evolve during the course of illness. This study identified inflammatory immune responses in septic patients receiving vitamin C, hydrocortisone, and thiamine.

METHODS

This was a single-center, post-hoc analysis of 95 patients with septic shock who received the vitamin C protocol. Blood samples were drawn on days 1-2, 3-4, and 6-8 after shock onset. Group-based multi-trajectory modeling was used to identify immune trajectory groups.

RESULTS

The median age was 78 years (interquartile range, 70-84 years), and 56% were male. Clustering analysis identified group 1 (n=41), which was characterized by lower interleukin (IL)-6, tumor necrosis factor (TNF)-α, and IL-10 levels, and these levels remained stationary or mildly increased until day 7. Conversely, group 2 (n=54) expressed initially higher IL-6, TNF-α, and IL-10 levels that decreased rapidly by day 4. There was a nonsignificant increase in lymphocyte count and a decrease in C-reactive protein level until day 7 in group 2. The intensive care unit mortality rate was significantly lower in group 2 (39.0% vs. 18.5%, P=0.03). Group 2 also had a significantly higher decrease in the mean (standard deviation) vasopressor dose (norepinephrine equivalent: -0.09±0.16 μg/kg/min vs. -0.23±0.31 μg/kg/min, P<0.001) and Sequential Organ Failure Assessment score (0±5 vs. -4±3, P=0.002) between days 1 and 4.

CONCLUSIONS

There may be different subphenotypes in septic patients receiving the vitamin C protocol.

Development and validation of prediction scores for the outcome associated with persistent inflammation, immunosuppression, and catabolism syndrome among patients with trauma

Background

Persistent inflammation, immunosuppression, and catabolism syndrome (PICS) has impacted on long-term prognosis of patients with trauma. We aimed to identify patients with trauma at risk of PICS-related complications early in the intensive care unit (ICU) course.

Methods

A single-center retrospective cohort study was conducted. All consecutive patients with trauma who had stayed in the ICU for >7 days were included in the study. We developed the prediction score for the incidence of PICS-related outcomes in the derivation cohort for the initial period and then evaluated in the validation cohort for the subsequent period. Other outcomes were also assessed using the score.

Results

In total, 170 and 133 patients were included in the derivation and validation cohorts, respectively. The prediction score comprised the variables indicating PICS presence, including a maximum value of C-reactive protein >15 mg/dL, minimum value of albumin <2.5 g/dL, and an episode of nosocomial infection for the first 7 days after admission. A score of 1 was assigned to each variable. The area under the receiver operating characteristic curve of the score to predict PICS incidence was 0.74 (95% CI 0.66 to 0.81) and 0.72 (95% CI 0.64 to 0.81) in the derivation and validation cohorts, respectively. The higher score was also significantly associated with a higher Sequential Organ Failure Assessment score at day 14, a longer duration of mechanical ventilation, a longer length of stay in ICU, and experienced multiple episodes of infection. Similar results were obtained in the validation cohort.

Conclusions

Our scoring system could predict the outcomes associated with PICS among patients with trauma. Because the score comprised the parameters measured for the first 7 days during the ICU course, it could contribute to identifying patients at a high risk of unfavorable outcome earlier.

Level of evidence

Multivariate prediction models; level IV.

Effects of Antithrombin on Persistent Inflammation, Immunosuppression, and Catabolism Syndrome among Patients with Sepsis-Induced Disseminated Intravascular Coagulation

Persistent inflammation, immunosuppression, and catabolism syndrome (PICS) is a serious condition after critical care. We examined the efficacy of antithrombin, which may attenuate coagulopathy with the control of inflammation, for PICS among patients with sepsis-induced disseminated intravascular coagulation (DIC). The present study used the inpatient claims database with laboratory findings to identify patients admitted to intensive care units and diagnosed with sepsis and DIC. A composite of the incidence of PICS on day 14 or 14-day mortality as the primary outcome was compared between the antithrombin and control groups using a propensity-score-matched analysis. Secondary outcomes were the incidence of PICS on day 28, 28-day mortality, and in-hospital mortality. A total of 324 well-balanced matched pairs were generated from 1622 patients. The primary outcome did not differ between the antithrombin and control groups (63.9% vs. 68.2%, respectively, p = 0.245). However, the incidences of 28-day and in-hospital mortality were significantly lower in the antithrombin group (16.0% vs. 23.5% and 24.4% vs. 35.8%, respectively). Similar results were obtained in a sensitivity analysis using overlap weighting. Antithrombin did not reduce the occurrence of PICS on day 14 in patients with sepsis-induced DIC; however, it was associated with a better mid-term (day 28) prognosis.

CLINICAL AND PROGNOSTIC FEATURES OF CHRONIC CRITICAL ILLNESS/PERSISTENT INFLAMMATION IMMUNOSUPPRESSION AND CATABOLISM PATIENTS: A PROSPECTIVE OBSERVATIONAL CLINICAL STUDY

ABSTRACT

Objective: The aims of this study were to investigate and compare the clinical features and prognosis of chronic critical illness (CCI)/persistent inflammation immunosuppression and catabolism (PICS). Methods: This is a prospective observational clinical study. During this study period, we collect intensive care unit patients' data from Suzhou Municipal Hospital and Suzhou Ninth People's Hospital. All patients older than 18 years were included, and according to the corresponding exclusion and diagnostic criteria, they were divided into four groups: PICS group, CCI group, CCI and PICS group (CCI + PICS), and neither CCI nor PICS group (NCCI + NPICS) and collected and recorded age, sex, hospital time, hospital diagnosis, Acute Physiology and Chronic Health Evaluation II score, Sequential Organ Failure Assessment score, C-reactive protein, absolute value lymphocyte count, serum albumin, white blood cell count, absolute value neutrophil count, secondary infection, and 28-day case fatality rate separately. Results: A total of 687 patients were admitted to the intensive care unit during the study period. The hospitalization time less than 14 days were excluded, and 168 patients were eventually included. There are 17 in the PICS group, 71 in the CCI group, 50 in the CCI + PICS group, and 30 in the NCCI + NPICS group. Baseline characteristics showed statistically significant differences in Sequential Organ Failure Assessment, length of hospital stay, and 28-day mortality among four groups. Baseline main indicator and multiple comparisons showed that the CCI + PICS group had longer hospital stay, worse prognosis, and more adverse outcomes. Multivariate analysis showed that final age, C-reactive protein on days 14 and 21, and serum albumin on days 1 and 21 had an impact on the prognosis ( P < 0.05). Conclusion: The clinical prognosis of the four groups decreased in order of NCCI + NPICS, CCI, PICS, and CCI + PICS. Our finding of clinically isolated PICS may indicate that PICS acts as an inducement or independent factor to worsen the prognosis of CCI.

Clinical Criteria for Persistent Inflammation, Immunosuppression, and Catabolism Syndrome: An Exploratory Analysis of Optimal Cut-Off Values for Biomarkers

Background: While clinical criteria have been proposed for persistent inflammation, immunosuppression, and catabolism syndrome (PICS) using C-reactive protein (CRP), albumin, and lymphocyte count, there is no substantial basis for their optimal cut-off values. We herein aimed to develop and externally validate clinical criteria for PICS by investigating the optimal cut-off values for these biomarkers using machine-learning approaches and confirmed it with external validation. Methods: To develop criteria, we included ICU patients treated at a tertiary care hospital in Japan between 2018 and 2021 (derivation cohort). We introduced CRP, albumin and lymphocyte counts at around day 14 into six machine-learning models to predict PICS, defined as the compound outcome of the Barthel index (BI) < 70 at hospital discharge and in-hospital death. We incorporated the results of these models to assess the optimal cut-off values for biomarkers. We then developed and externally validated criteria for PICS using a nationwide claims database in Japan (validation cohort). Results: In the derivation cohort, 291 out of 441 patients had BI < 70 or in-hospital death. Based on machine-learning models, the optimal cut-off values for biomarkers to predict them were a CRP of 2.0 mg/dL, albumin of 3.0 g/dL, and a lymphocyte count of 800/μL, with an AUROC of 0.67. In the external validation cohort, 4492 out of 15,302 patients had BI < 70 or in-hospital death. The AUROC of the criteria was 0.71, with sensitivity of 0.71 and specificity of 0.68 to predict PICS. Conclusions: We herein provide a fundamental basis for PICS clinical criteria with CRP >2.0 mg/dL, albumin <3.0 g/dL, and a lymphocyte count <800/μL on day 14. The criteria developed will identify patients with PICS whose long-term mortality and activity of daily living may be poor.

Prevalence and Risk Factor Analysis of Post-Intensive Care Syndrome in Patients with COVID-19 Requiring Mechanical Ventilation: A Multicenter Prospective Observational Study

Introduction: Post-intensive care syndrome (PICS) is an emerging problem in critically ill patients and the prevalence and risk factors are unclear in patients with severe coronavirus disease 2019 (COVID-19). This multicenter prospective observational study aimed to investigate the prevalence and risk factors of PICS in ventilated patients with COVID-19 after ICU discharge. Methods: Questionnaires were administered twice in surviving patients with COVID-19 who had required mechanical ventilation, concerning Barthel Index, Short-Memory Questionnaire, and Hospital Anxiety and Depression Scale scores. The risk factors for PICS were examined using a multivariate logistic regression analysis. Results: The first and second PICS surveys were obtained at 5.5 and 13.5 months (mean) after ICU discharge, with 251 and 209 patients completing the questionnaires and with a prevalence of PICS of 58.6% and 60.8%, respectively, along with the highest percentages of cognitive impairment. Delirium (with an odds ratio of (OR) 2.34, 95% CI 1.1–4.9, and p = 0.03) and the duration of mechanical ventilation (with an OR of 1.29, 95% CI 1.05–1.58, and p = 0.02) were independently identified as the risk factors for PICS in the first PICS survey. Conclusion: Approximately 60% of the ventilated patients with COVID-19 experienced persistent PICS, especially delirium, and required longer mechanical ventilation.

Hypercatabolism and Anti-catabolic Therapies in the Persistent Inflammation, Immunosuppression, and Catabolism Syndrome

Owing to the development of intensive care units, many patients survive their initial insults but progress to chronic critical illness (CCI). Patients with CCI are characterized by prolonged hospitalization, poor outcomes, and significant long-term mortality. Some of these patients get into a state of persistent low-grade inflammation, suppressed immunity, and ongoing catabolism, which was defined as persistent inflammation, immunosuppression, and catabolism syndrome (PICS) in 2012. Over the past few years, some progress has been made in the treatment of PICS. However, most of the existing studies are about the role of persistent inflammation and suppressed immunity in PICS. As one of the hallmarks of PICS, hypercatabolism has received little research attention. In this review, we explore the potential pathophysiological changes and molecular mechanisms of hypercatabolism and its role in PICS. In addition, we summarize current therapies for improving the hypercatabolic status and recommendations for patients with PICS.

Immune Profiling Demonstrates a Common Immune Signature of Delayed Acquired Immunodeficiency in Patients With Various Etiologies of Severe Injury

OBJECTIVES

The host response plays a central role in the pathophysiology of sepsis and severe injuries. So far, no study has comprehensively described the overtime changes of the injury-induced immune profile in a large cohort of critically ill patients with different etiologies.

DESIGN

Prospective observational cohort study.

SETTING

Adult ICU in a University Hospital in Lyon, France.

PATIENTS

Three hundred fifty-three septic, trauma, and surgical patients and 175 healthy volunteers were included in the REAnimation Low Immune Status Marker study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Extensive immune profiling was performed by assessing cellular phenotypes and functions, protein, and messenger RNA levels at days 1-2, 3-4, and 5-7 after inclusion using a panel of 30 standardized immune markers. Using this immunomonitoring panel, no specificity in the immune profile was observed among septic, trauma, and surgical patients. This common injury-induced immune response was characterized by an initial adaptive (i.e., physiologic) response engaging all constituents of the immune system (pro- and anti-inflammatory cytokine releases, and innate and adaptive immune responses) but not associated with increased risk of secondary infections. In contrary, the persistence in a subgroup of patients of profound immune alterations at the end of the first week after admission was associated with increased risk of secondary infections independently of exposure to invasive devices. The combined monitoring of markers of pro-/anti-inflammatory, innate, and adaptive immune responses allowed a better enrichment of patients with risk of secondary infections in the selected population.

CONCLUSIONS

Using REAnimation Low Immune Status Marker immunomonitoring panel, we detected delayed injury-acquired immunodeficiency in a subgroup of severely injured patients independently of primary disease. Critically ill patients' immune status could be captured through the combined monitoring of a common panel of complementary markers of pro-/anti-inflammatory, innate, and adaptive immune responses. Such immune monitoring needs to be incorporated in larger study cohorts with more extensive immune surveillance to develop specific hypothesis allowing for identification of biological systems affecting altered immune function related to late infection in the setting of acute systemic injury.

Effects of evidence-based ICU care on long-term outcomes of patients with sepsis or septic shock (ILOSS): protocol for a multicentre prospective observational cohort study in Japan

INTRODUCTION

Sepsis is not only the leading cause of death in the intensive care unit (ICU) but also a major risk factor for physical and cognitive impairment and mental disorders, known as postintensive care syndrome (PICS), reduced health-related quality of life (HRQoL) and even mental health disorders in patient families (PICS-family; PICS-F). The ABCDEF bundle is strongly recommended to overcome them, while the association between implementing the bundle and the long-term outcomes is also unknown.

METHODS AND ANALYSIS

This is a multicentre prospective observational study at 26 ICUs. All consecutive patients between 1 November 2020 and 30 April 2022, who are 18 years old or older and expected to stay in an ICU for more than 48 hours due to sepsis or septic shock, are enrolled. Follow-up to evaluate survival and PICS/ PICS-F will be performed at 3, 6 and 12 months and additionally every 6 months up to 5 years after hospital discharge. Primary outcomes include survival at 12 months, which is the primary outcome, and the incidence of PICS defined as the presence of any physical impairment, cognitive impairment or mental disorders. PICS assessment scores, HRQoL and employment status are evaluated. The association between the implementation rate for the ABCDEF bundle and for each of the individual elements and long-term outcomes will be evaluated. The PICS-F, defined as the presence of mental disorders, and HRQoL of the family is also assessed. Additional analyses with data up to 5 years follow-up are planned.

ETHICS AND DISSEMINATION

This study received ethics approvals from Saiseikai Utsunomiya Hospital (2020-42) and all other participating institutions and was registered in the University Hospital Medical Information Network Clinical Trials Registry. Informed consent will be obtained from all patients. The findings will be published in peer-reviewed journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

UMIN000041433.

Characterization of Early Peripheral Immune Responses in Patients with Sepsis and Septic Shock

(1) Background: Sepsis is a life-threatening condition caused by an abnormal host response to infection that produces altered physiological responses causing tissue damage and can result in organ dysfunction and, in some cases, death. Although sepsis is characterized by a malfunction of the immune system leading to an altered immune response and immunosuppression, the high complexity of the pathophysiology of sepsis requires further investigation to characterize the immune response in sepsis and septic shock. (2) Methods: This study analyzes the immune-related responses occurring during the early stages of sepsis by comparing the amounts of cytokines, immune modulators and other endothelial mediators of a control group and three types of severe patients: critically ill non-septic patients, septic and septic shock patients. (3) Results: We showed that in the early stages of sepsis the innate immune system attempts to counteract infection, probably via neutrophils. Conversely, the adaptive immune system is not yet fully activated, either in septic or in septic shock patients. In addition, immunosuppressive responses and pro-coagulation signals are active in patients with septic shock. (4) Conclusions: The highest levels of IL-6 and pyroptosis-related cytokines (IL-18 and IL-1α) were found in septic shock patients, which correlated with D-dimer. Moreover, endothelial function may be affected as shown by the overexpression of adhesion molecules such as s-ICAM1 and E-Selectin during septic shock.

Deprivation of Dietary Fiber Enhances Susceptibility of Piglets to Lung Immune Stress

Growing evidence suggests that dietary fiber enhances short-chain fatty acid (SCFA) producing gut microbes, improving lung immunity against invading pathogens via the gut–lung axis. This study investigated the effects of dietary fiber on lung immune stress after challenge with complete Freund's adjuvant (CFA) containing killed Mycobacterium tuberculosis. Thirty-six healthy hybrid Duroc, Landrace, and Yorkshire male piglets (9.7 ± 1.07 kg, 35 ± 3 days) were randomly fed a low fiber (LF) diet formulated with semipurified corn starch, soy protein concentrate, and fishmeal or a high fiber (HF) diet composed of 1,000 g LF diet plus 20 g inulin, and 100 g cellulose. Piglets were housed individually in the metabolism cages with eighteen replicates per group, with one pig per cage. All the piglets received similar levels of digestible energy and lysine and had similar weight gain. After dietary treatment for 28 days, nine piglets per group were intravenously administered CFA (0.4 mg/kg) or an equivalent amount of sterile saline in a 2 × 2 factorial arrangement. In piglets fed the LF diet, CFA caused lung damage and elevated serum C-reactive protein and relative mRNA expression of genes related to lung inflammation (NLRP3, Casp1, ASC, IL1β, IL18, Bax). Compared with the LF diet, the HF diet increased bacterial diversity and Deferribacteres (p = 0.01) in the phylum level and unidentified_Ruminococcaceae (p = 0.03) and Catenisphaera (p < 0.01) in the genus level. The HF diet improved increased short-chain fatty acids in feces, blood, cecal, and colonic digesta; reduced lung damage; and promoted lung recovery. Overall, dietary fiber deprivation enhanced the risk of piglets to lung immune stress, demonstrating the importance of dietary fiber in gut–lung health.

Mouse Model of Critical Persistent Inflammation, Immunosuppression, and Catabolism Syndrome

ABSTRACT

Persistent inflammation, immunosuppression, and catabolism syndrome (PIICS) is a growing challenge in intensive care units (ICUs). PIICS causes a severe illness with high mortality. Currently, treatment is expensive, and the outcomes are dismal. Herein, we established a PIICS model to study the disease pathophysiology and its potential treatment. Using a modified sublethal cecal ligation and puncture (CLP) to induce sepsis (day 1) and the injection of lipopolysaccharide (LPS) to induce an aggravated inflammation response (day 11), CLP + LPS mice recapitulating PIICS features were successfully generated (day 14). Adult male mice were divided into CLP + LPS, CLP + daily chronic stress (DCS), CLP, DCS, LPS, and sham control groups. A survival curve was generated, and phenotypes were analyzed using markers for catabolism, inflammation, and immunosuppression. The CLP + LPS model showed two mortality peaks (after CLP and after LPS), whereas the CLP + DCS and CLP groups showed one peak. Surviving CLP + LPS mice exhibited significantly increased catabolism and inflammatory cytokine levels and aggravated inflammation, including organ inflammation. CLP + LPS mice exhibited strong immune suppression as evidenced by decreased splenic cluster of differentiation (CD)8+ and interferon-γ+CD8+ T cell counts and a concomitant and significant increase in the myeloid-derived suppressor cell population. This CLP+LPS-induced PIICS model differs from acute sepsis models, showing two mortality peaks and a protracted course of 14 days. Compared to previous PIICS models, ours shows a re-aggravated status and higher catabolism, inflammation, and immunosuppression levels. Our aim was to use the PIICS model to simulate PIICS pathophysiology and course in the ICU, enabling investigation of its mechanism and treatment.

Association of red blood cell and platelet transfusions with persistent inflammation, immunosuppression, and catabolism syndrome in critically ill patients

The objective of this single-center retrospective cohort study was to investigate the relationship between blood transfusion and persistent inflammation, immunosuppression, and catabolism syndrome (PIICS). The study was conducted at the Critical Care Center at Toho University Omori Medical Center, Japan. We included 391 patients in the PIICS group (hospitalization for > 15 days, C-reactive protein > 3.0 mg/dL or albumin < 3.0 mg/dL or lymph < 800/μL on day 14) and 762 patients in the non-PIICS group (hospitalization for > 15 days and not meeting the PIICS criteria). We performed univariate and multivariate logistic regression analyses using PIICS as the objective variable and red blood cell (RBC) or fresh frozen plasma or platelet (PLT) transfusion and other confounding factors as explanatory variables. In addition, we conducted a sensitivity analysis using propensity score matching analysis. The multivariate and propensity score analyses showed that RBC and PLT transfusions were significantly associated with PIICS. This is the first study to report an association between RBC and PLT transfusions and PIICS. Our findings have contributed to better understanding the risk factors of PIICS and suggest that physicians should consider the risk of PIICS occurrence when administering blood transfusions in intensive care unit (ICU) patients.

C-REACTIVE PROTEIN AS A MARKER OF CLINICAL AND LABORATORY REMISSION IN PATIENTS WITH ACUTE NECROTIZING PANCREATITIS

OBJECTIVE

The aim: To estimate the role of C-reactive protein levels as a marker of clinical and laboratory remission in patients with acute necrotizing pancreatitis.

PATIENTS AND METHODS

Materials and methods: A single-center retrospective non-randomized study of 68 patients (37 (54%) men, 31 (46%) women) was carried out in the period from September 2019 to October 2020. The patients were divided into two groups: group 1 included 9 (13.2%) patients rehospitalized within a month of observation after being discharged from hospital with improvement, group 2 consisted of 59 (86.8%) patients not readmitted within the observation period. A standard package of Microsoft Excel, program MedStat v.5.2, W-test Wilcoxon and the Fisher transform was used to record, calculate and compare data.

RESULTS

Results: Patients in groups 1 and 2 did not statistically differ in age (p = 0.727), gender (p = 0.202), body mass index (BMI) (p = 0.447), length of hospital stay (p = 0.913), volume of pancreatic lesion according to СTSI (p = 0.313) and severity of disease (p = 0.205). Incidence of pancreatic necrosis infection was 88.8% (p = 0.007) in group 1 versus 35.6% in group 2. In the group of rehospitalized patients, the level of C-reactive protein upon discharge was significantly higher (Me ± m 80.8± 9.734 (66) -88), CI 95%) compared with the patients from the group without readmission (Me ± m 21.36± 2.285 (16.1-31.1) CI 95%) p <0.001. As the "critical" CRP level for group 1, indicating readmission for infectious complications of AP, was chosen the value of the left limit of 95% CI (confidence interval), which made up ≥64.5 mg / ml.

CONCLUSION

Conclusions: According to the results of our study, the risk of readmission in patients with CRP level ≥64.5 mg / L prior to being discharged exceeded 41 times the risk of readmission in those with lower CRP values (RR 41.5 ± 1.008 (95% CI 5.75-299, p = 0.04)). For each patient with CRP levels ≥64.5 mg / L, the risk of readmission within the first month after being discharged was 71% (95% CI 40.7-88.6, p = 0.03).

Severity of early diagnosed organ/space surgical site infection in elective gastrointestinal and hepatopancreatobiliary surgery

Background

Organ/space surgical site infection (SSI) is a significant clinical problem. The postdiagnosis course of organ/space SSIs and the impact of its early diagnosis on clinical outcomes are yet to be clarified. Thus, we aimed to investigate the association between the timing of diagnosis and the clinical outcome of organ/space SSI.

Methods

This retrospective, single‐center cohort study evaluated patients who underwent elective gastrointestinal or hepatopancreatobiliary surgery between 2016 and 2020. Clinical outcomes were compared between the early group (ie, SSI diagnosed until postoperative day [POD] 4) and normal‐late group (ie, SSI diagnosed after POD 5). The primary outcome was the final C‐reactive protein (CRP) level within 14 d after organ/space SSI diagnosis.

Results

In total, 110 patients were evaluated. The median time of diagnosis was 7 d postoperatively (interquartile range, 5–9 d postoperatively). Compared with the normal‐late group, the early group included a higher proportion of patients with Clavien–Dindo grade ≥IIIb (8/21 vs 11/89, P = .01), higher final CRP value within 14 d after SSI diagnosis (mean, 4.49 mg/dL vs 2.27 mg/dL, P = .01), longer postoperative length of hospitalization (median, 45.0 d vs 33.0 d; P = .028), and worse 1‐y overall survival rate (74.8% vs 89.3%, P = .08).

Conclusion

Early diagnosed organ/space SSI are originally severe and may therefore be detected earlier. Importantly, early diagnosed organ/space SSI is likely to be severe and refractory.

Cystatin C and/or creatinine-based estimated glomerular filtration rate for prediction of vancomycin clearance in long-stay critically ill patients with persistent inflammation, immunosuppression and catabolism syndrome (PICS): a population pharmacokinetics analysis

Persistent inflammation, immunosuppression and catabolism syndrome (PICS) in critically ill patients are associated with unreliable creatinine (Cr)-based estimated glomerular filtration rate (eGFR) and alteration in vancomycin clearance (CL) due to ongoing muscle wasting and renal dysfunction (RD). Currently, cystatin C (Cys) is of great interest for eGFR due to its muscle independence. Patients receiving intravenous vancomycin with trough concentration monitoring after intensive care unit stay ≥ 14 days were retrospectively enrolled. Those with C-reactive protein > 30.0 mg/L, lymphocytes count < 0.80 × 10⁹, albumin < 30 mg/L and weight loss > 10% were diagnosed with PICS. Impact of PICS on vancomycin trough achievement was analyzed. Plasma Cys and Cr levels with their eGFRs in RD were compared in patients with and without PICS. Furthermore, the performance of eGFRs in predicting vancomycin CL was quantificationally evaluated by population pharmacokinetics (PPK) analysis using the Phoenix NLME software. Of 69 enrolled patients, 32 (46.4%) were PICS. PICS was predictive of Cr-guided vancomycin supratherapeutic trough concentrations (OR = 5.26, P = 0.013). Significant elevation of Cys, not of Cr, was observed in patients with PICS suffering from RD (P = 0.022), causing substantial differences among eGFRs. Fifty-two and 17 patients were enrolled for the modeling group and validation group, respectively. A one-compartment PPK model with first-order elimination adequately described the data of 126 C_trough. Prediction of vancomycin CL with Cys and Cr-based eGFR (CKD-EPI_cys-cr) significantly reduced the interindividual variability of CL (from 75.6 to 28.5%). External validation with 34 C_trough showed the robustness and accuracy of this model. This study showed the negative impact of PICS on Cr-guided vancomycin trough achievement. PPK model with CKD-EPI_cys-cr can be used to optimize vancomycin dosage in patients with PICS.

Urinary Titin N-Fragment as a Biomarker of Muscle Atrophy, Intensive Care Unit-Acquired Weakness, and Possible Application for Post-Intensive Care Syndrome

Titin is a giant protein that functions as a molecular spring in sarcomeres. Titin interconnects the contraction of actin-containing thin filaments and myosin-containing thick filaments. Titin breaks down to form urinary titin N-fragments, which are measurable in urine. Urinary titin N-fragment was originally reported to be a useful biomarker in the diagnosis of muscle dystrophy. Recently, the urinary titin N-fragment has been increasingly gaining attention as a novel biomarker of muscle atrophy and intensive care unit-acquired weakness in critically ill patients, in whom titin loss is a possible pathophysiology. Furthermore, several studies have reported that the urinary titin N-fragment also reflected muscle atrophy and weakness in patients with chronic illnesses. It may be used to predict the risk of post-intensive care syndrome or to monitor patients' condition after hospital discharge for better nutritional and rehabilitation management. We provide several tips on the use of this promising biomarker in post-intensive care syndrome.

ICU-Acquired Hypernatremia Is Associated with Persistent Inflammation, Immunosuppression and Catabolism Syndrome

Developing hypernatremia while on intensive care unit (ICU) is a common problem with various undesirable effects. A link to persistent inflammation, immunosuppression and catabolism syndrome (PICS) can be established in two ways. On the one hand, hypernatremia can lead to inflammation and catabolism via hyperosmolar cell stress, and on the other, profound catabolism can lead to hypernatremia via urea-induced osmotic diuresis. In this retrospective single-center study, we examined 115 patients with prolonged ICU stays (≥14 days) and sufficient renal function. Depending on their serum sodium concentrations between ICU day 7 and 21, allocation to a hypernatremic (high) and a nonhypernatremic group (low) took place. Distinct signs of PICS were detectable within the complete cohort. Thirty-three of them (28.7%) suffered from ICU-acquired hypernatremia, which was associated with explicitly higher signs of inflammation and ongoing catabolism as well as a prolonged ICU length of stay. Catabolism was discriminated better by the urea generation rate and the urea-to-creatinine ratio than by serum albumin concentration. An assignable cause for hypernatremia was the urea-induced osmotic diuresis. When dealing with ICU patients requiring prolonged treatment, hypernatremia should at least trigger thoughts on PICS as a contributing factor. In this regard, the urea-to-creatinine ratio is an easily accessible biomarker for catabolism.

Validation of chief complaints, medical history, medications, and physician diagnoses structured with an integrated emergency department information system in Japan: the Next Stage ER system

Aim

Emergency department information systems (EDIS) facilitate free‐text data use for clinical research; however, no study has validated whether the Next Stage ER system (NSER), an EDIS used in Japan, accurately translates electronic medical records (EMRs) into structured data.

Methods

This is a retrospective cohort study using data from the emergency department (ED) of a tertiary care hospital from 2018 to 2019. We used EMRs of 500 random samples from 27,000 ED visits during the study period. Through the NSER system, chief complaints were translated into 231 chief complaint categories based on the Japan Triage and Acuity Scale. Medical history and physician’s diagnoses were encoded using the International Classification of Diseases, 10th Revision; medications were encoded as Anatomical Therapeutic Chemical Classification System codes. Two reviewers independently reviewed 20 items (e.g., presence of fever) for each study component (e.g., chief complaints). We calculated association measures of the structured data by the NSER system, using the chart review results as the gold standard.

Results

Sensitivities were very high (>90%) in 17 chief complaints. Positive predictive values were high for 14 chief complaints (≥80%). Negative predictive values were ≥96% for all chief complaints. For medical history and medications, most of the association measures were very high (>90%). For physicians’ ED diagnoses, sensitivities were very high (>93%) in 16 diagnoses; specificities and negative predictive values were very high (>97%).

Conclusions

Chief complaints, medical history, medications, and physician’s ED diagnoses in EMRs were well‐translated into existing categories or coding by the NSER system.

Disseminated Intravascular Coagulopathy Is Associated with the Outcome of Persistent Inflammation, Immunosuppression and Catabolism Syndrome

Persistent inflammation, immunosuppression and catabolism syndrome (PIICS) often occur after critical care. Disseminated intravascular coagulation (DIC) is expected to be associated independently with PIICS development. We retrospectively analyzed 5397 patients admitted to the Hitachi General Hospital emergency and critical care center during four years. We classified PIICS as C-reactive protein > 3.0 mg/dL or albumin < 3.0 g/dL or lymphocyte count < 800/μL on day 14. Prolonged hospital stay (>14 days) without PIICS and early recovery (discharged alive within 14 days) were assigned as non-PIICS. Early death (death within 14 days) was identified. We analyzed the association between the International Society on Thrombosis and Haemostasis overt DIC and PIICS outcomes. Results revealed 488 PIICS, 416 early death and 4493 non-PIICS cases. Analyses showed DIC as associated significantly with mortality, the Barthel index at discharge and PIICS development. Multivariate regression analysis and a generalized structural equation model identified DIC on admission as an independent risk factor for PIICS in surviving patients.

High protein versus medium protein delivery under equal total energy delivery in critical care: A randomized controlled trial

BACKGROUND

Appropriate protein delivery amounts during the acute phase of critical care are unknown. Along with nutrition, early mobilization and the combination are important. We conducted a randomized controlled trial during critical care to assess high-protein and medium-protein delivery under equal total energy delivery with and without active early rehabilitation.

METHODS

ICU patients of August 2018-September 2019 were allocated to a high-protein group (target energy 20 kcal/kg/day, protein 1.8 g/kg/day) or a medium-protein group (target energy 20 kcal/kg/day, protein 0.9 g/kg/day) with the same nutrition protocol by day 10. By dividing the study period, standard rehabilitation was administered during the initial period. Rehabilitation with belt-type electrical muscle stimulation was given from day 2 in the latter as a historical comparison. Femoral muscle volume was evaluated on day 1 and day 10 using computed tomography.

RESULTS

This study analyzed 117 eligible patients with similar characteristics assigned to a high-protein or medium-protein group. Total energy delivery was around 20 kcal/kg/day in both groups, but protein delivery was 1.5 g/kg/day and 0.8 g/kg/day. As a primary outcome, femoral muscle volume loss was 12.9 ± 8.5% in the high-protein group and 16.9 ± 7.0% in the medium-protein group, with significant difference (p = 0.0059). Persistent inflammation, immunosuppression, and catabolism syndrome were significantly less frequent in the high-protein group. Muscle volume loss was significantly less in the high-protein group only during the electrical muscle stimulation period.

CONCLUSIONS

For critical care, high protein delivery provided better muscle volume maintenance, but only with active early rehabilitation.

REGISTRATION

University Hospital Medical Information Network, UMIN000033783 Registered on 16 Aug 2018. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000038538.